How not to cope with a setback

Forget there is a setback plan, try to get back to ‘normal’ as quickly as possible, then have half a bar of chocolate and a third of a bottle of wine because what’s the point in trying to be good if you end up feeling horrible anyway?

Still it’s a new week, so I’m going to attempt a new start. Dig out the set back plan, ease myself back into good routines and habits and remind myself that set backs are always going to be a part of chronic illness, no matter how careful I am.

And it’s not the end of the world if I mess up sometimes.

What is Compassion Focused Therapy?

Compassion Focused Therapy (CFT) is an offshoot of CBT.  It was designed for people with high levels of self-criticism or shame.   It is supposed to be helpful for people who can reason against their fears or beliefs but who find that their feelings don’t change.

The theory behind CFT is that we have evolved a set of mental systems because they helped our ancestors survive.   The relevant ones are the drive and motivation system (search for something, feel rewarded, want to search again), the threat and protect system (recognise danger and activate the fight/flight/freeze response) and the soothing and contentment system.  Due to our genes, our early experiences and our environment some of us have overdeveloped threat systems and undeveloped soothing systems.  CFT teaches us to redress the balance by developing our soothing system.  There are a core set of exercises which include meditations, imagination and imagery and thinking through beliefs and coping mechanisms.

There are self-help resources available and I’ve linked to a few below. CFT exercises can touch on difficult and painful issues and memories so a lot of resources suggest it may be better to work with a therapist.  That was true in my case.

How good is the evidence for CFT?

A 2014 study says there isn’t enough of the kind of research necessary to consider CFT to be evidence based. Studies have been conducted but they generally have too few people participating in them, or other limitations. This means that we don’t know if CFT is better than existing treatments.

My personal experience with CFT: 

It has been difficult, bringing up some difficult emotions but I feel it is worth it to soften that critical voice in my head and to learn to look after myself better and more kindly.  I started with CFT in one to one high intensity CBT sessions where we talked through some of my early experiences, my beliefs, fears and my feelings about myself.  I’ve found the group therapy sessions I’m currently going to really helpful.  The theory and techniques are introduced gradually and repeated so it’s not too threatening and I’m gradually opening up to a new way of thinking.  I can see there’s an awful lot of work to be done and it’s going to take a lot of time and patience.  But I’m really looking to forward to having a calmer more compassionate way of talking to myself and responding to mistakes and difficulties.

How do I think CFT fits into self-management of chronic illness?

  • A chance to develop new or better coping strategies if our old ones are no longer accessible.  For example, worrying, perfectionism, and over-preparing are not ideal ways of coping but they may have been okay in the past.  But they take up far too much precious time and energy for a chronically ill person.
  • An antidote to criticism and judgement from ourselves, people around us and in the media.
  • Learn to support ourselves in doing what is best for ourselves, even when it is hard.
  • Learn to support ourselves in accepting and coming to terms with the changes to our lives.
  • Learning to alleviate anxiety and fear.
  • Learning to address unhelpful beliefs with understanding and kindness.

Resources

  • Compassionate Mind Foundation
  • Paul Gilbert, Overcoming Depression A long and detailed book that I found really helpful. It’s written clearly, with some memorable turns of phrase and exercises to practise with.  This is my favourite because it strikes the right balance of depth of explanation and practical exercises for me.
  • Mary Welford, A Compassionate Mind Approach to Building Self-Compassion A shorter, easier read than Overcoming Depression with exercises to work through. Some of the exercises on thinking about where my lack of confidence had come from were emotionally challenging. I was glad I had covered some of this with a counsellor before reading the book.
  • Paul Gilbert, The Compassionate Mind (I’m only half way through this book so far) I like reading about the background to how the therapy was developed and where research is going.  However, there may be more detailed theory here than some people will enjoy.  I like that Paul Gilbert acknowledges the role of our culture and social context in producing an environment that isn’t supportive of compassion.
  • Kristen Neff website Meditations and exercises
  • Chris Germer website Meditations and exercises
  • CCI Self-Compassion A series of 7 workbooks (PDF) introducing concepts and exercises for building self-compassion.

Soothing breathing

I have encountered soothing breathing exercises as part on my one-to-one counselling and when reading self-help Compassion Focused Therapy (CFT) books.  It’s not something that I persisted with though.  Developing a soothing breathing technique or form of imagery that helps us to feel calm, soothed and steady has been the main practical exercise for the first 5 weeks of my group therapy.  This soothing practice came alongside getting to grips with the theory and principles of CFT.

Now that we are getting into applying the theory to understanding our own experiences and fears I think I understand the importance of learning soothing rhythm breathing first.  Thinking about the lack of compassion I have for myself, how critical I am of myself and how I came to be this was raises a lot of sadness, and some fears to the surface.  Being able to calm myself is really helpful in being able to do think about and discuss these thoughts and feelings, without feeling overwhelmed or crushed by them.

I’ve practised soothing breathing rhythm on most days since we were introduced to it in the first week.  I’ve also experimented with scent, imagery and holding an object.  I’ve discovered I like the scent of lavender because I associate it with relaxation and it encourages me to inhale deeply.  I also like to hold a pebble in my hand.  The shape and texture gives me something to focus my attention on if I’m having a hard time settling down.  After practising for several weeks I have noticed I find it easier to calm myself and soothe the effects of anxiety or stress in my mind and body and to get a little relief.  I used soothing rhythm breathing during an extremely stressful event last week and coped much better than usual.

Pacing progress update

The aim of pacing is to find the approximate length of time that I can work at something without causing a flare up in my symptoms. The principles of pacing are to avoid a cycle of boom and bust and to stop before you need a break. A few months ago I worked out my starting baselines for various activities. I’m working on gradually increasing my baselines by one minute a week for two activities at a time.

Pacing:

Overall I’m starting to see benefits from pacing my activities to reduce flare ups in fatigue and pain. I still struggle with some of the drawbacks. For example, I can’t get into a ‘flow state‘ when I’m only engaging in something for a maximum of 8 minutes at a time. And it’s taking a lot of time, thought and energy to implement pacing in my life.

I’ve been doing some problem solving around the various issues as they arise which makes things a little easier. I can also see an improvement in terms of how comfortable I am as I’m aggravating the pain and dizziness less. This is particularly noticeable towards the end of the day. I have to go to bed less during the day to sleep. Though I still have scheduled rest breaks where I lie down to relax or meditate and I still do to bed at the onset of a migraine.

The changes:

Flow:

I’ve experimented with grouping tasks into sets of 4. I have a 3 minute break after each task to check in, and a longer relaxation period of around 25 minutes after each set of 4. I’m aiming to group activities so I keep some continuity in where my mind is at throughout each set, and variety in how I use my body from one task to the next. Pairing activities that I do regularly reduces the planning and decisions that need to be made each day.

  • Planning (computer) / Balance exercises
  • Reading or dictation / housework
  • Writing (computer) / dictation or thinking

Frustration with the timer:

Each morning I have started breaking down tasks I plan to do that day into smaller steps that match the time I’m allowed by my pacing strategy. This seems to reduce the frustration that comes from constantly being interrupted by the timer when I’m in the middle of something. Hopefully as time goes on I’ll get better at estimating the time needed for different tasks.

New baselines:

  • Housework
    • I’ve settled at 8 minutes at a time for general housework. I did try a week at 9 minutes but was getting very tired sometimes so reduced it back to 8 minutes. I’m planning to leave housework at this level for now.
    • I noticed I was getting very sore muscles after jobs involving stirring or scrubbing despite keeping to my time limit. I’ve made a separate category for housework involving intensive/ repetitive movement. This category has a starting baseline of 1 minute.
    • I’m alternating housework with reading or dictation which can be done with my feet up and head supported so I don’t overuse muscles. This allows me to process what I’m thinking about while doing the housework and to give my muscles a break while I read or record my thoughts.
  • Computer
    • Using wrist splints reduces pain.
    • Currently up to 8 minutes. I’ll see how that goes this week.

You can see how long it’s taken me to get to this stage in the pictures of my record sheets below. On the one hand, I’m happy that I have doubled the amount of time I can spend at the computer in two months. On the other hand, it’s taken two months and I can still only do 8 minutes which is a long way off what I want. This is where my self-compassion course, and the support of a health professional in setting and persevering with the pacing process has been so valuable. I’ve also appreciated encouragement and support from the people around me. I’m not sure I could have persevered without it.

Baseline Record Sheet: Computer
Baseline Record Sheet: Housework

Mindfulness:

  • More aware that I do need to pay attention when doing housework.
    • Thinking about how I’m going to lift something and if it’s a good idea
    • Noticing any muscles or joint aching or fatigue
    • Thinking about whether to continue with a plan or stop and change to another activity or rest.
  • I much preferred it when I could do housework on autopilot with my mind on something more interesting.

Finally – I can see some progress with pacing!

The aim of pacing is to find the approximate length of time that I can work at something without causing a flare up in my symptoms. The principles of pacing are to avoid a cycle of boom and bust by stopping before you need a break. A few months ago I worked out my baselines for various activities. I’m working on gradually increasing my baselines by one minute a week for two activities at a time.

The activities I have been working on are housework and using the computer. At the start of this week I increased the time spent on housework to 9 minutes, and time spent at the computer to 7 minutes

Using the computer is still comfortable, as long as I wear my wrist splint. This means I can increase the time allowed for the computer to 8 minutes. I do need to make sure I alternate using the computer with something away from my desk and making very light use of my hands. Dictation, reading, or using my whiteboard could all be good activities to alternate with the PC so I can keep my train of thought going while not aggravating any one particular symptom for too long.

I really want to increase time allocated to housework to 10 minutes as it’s a round number, but I felt tired few times after the 9 minutes this week. I also need to take care during the 9 minutes if I’m doing repetitive actions like stirring a saucepan or scrubbing or cleaning the bath. Several times doing activities like these within the 9 minutes has produced aching muscles and painful joints.

So I’m going to leave housework at an untidy 9 minutes. I’m also going to make a new category in my pacing list for repetitive housework tasks. I’ll start this at a baseline of 1 minutes and build up slowly from there.

Pacing like this is still frustrating although I am more accepting of it and it’s becoming a habit. I can see some benefit though. I’ve less pain in my hands particularly and while I’m tired at the end of the day, I’m not sleeping as much in the daytime.

Practising… Self-Compassion 4

Week 4: Compassion vs. Criticism

I believe that having self-compassion is essential if I’m going to live a meaningful life with chronic illness.  Unfortunately I’m not very good at it.  I think self-compassion is so important because it’s an attitude that encourages us to take good care of ourselves, to recognise how difficult life with a chronic condition can be, to be accepting of our limitations and appreciative of our efforts. 

For some of us (including myself) self-compassion isn’t something we developed as we grew up.  Instead we have an extremely vocal and opinionated inner critic.  This critical voice is always pointing out our failings, worrying about our weaknesses and generally making life even harder than it needs to be.  Continue reading Practising… Self-Compassion 4

Practising… Self-Compassion 1-3

I believe that having self-compassion is essential if I’m going to live a meaningful life with chronic illness.  Unfortunately I’m not very good at it.  I think self-compassion is so important because it’s an attitude that encourages us to take good care of ourselves, to recognise how difficult life with a chronic condition can be, to be accepting of our limitations and appreciative of our efforts. 

For some of us (including myself) self-compassion isn’t something we developed as we grew up.  Instead we have an extremely vocal and opinionated inner critic.  This critical voice is always pointing out our failings, worrying about our weaknesses and generally making life even harder than it needs to be.  Continue reading Practising… Self-Compassion 1-3

Android Apps for Calming Rhythmic Breathing

Calming rhythmic breathing is a technique for reducing the physical symptoms of anxiety by controlling your breathing rate.  There are a number of apps for mobile phone that can teach you this breathing technique, and I review a few of these below.  Continue reading Android Apps for Calming Rhythmic Breathing

Making a ‘first aid kit’ for depression

I’ve been struggling with mild depression for the last five days or so. I’ve put into practice a couple of the techniques that I learnt during my counselling sessions and I’ve got support from my partner and friends. But I realised that I have forgotten several things that helped in the past. And I’ve made it harder for myself because they aren’t noted down anywhere. When I’m starting feel very down and hopeless it’s better if I don’t have to search through notebooks and folders or rely on my memory. To fix this I’ve made a list of my remedies for mild to moderate depression that I will use now and have to hand next time.

My own first aid kit for depression:

  • Kristen Neff’s Soften Soothe and Allow meditation for calming the physical sensations of depression in my body.
  • Chocolate.
  • Sunshine (if available), if not try and get outside for a bit anyway.
  • Get outside, visit my allotment. Go, even if you don’t feel up to doing anything when you get there.
  • “You have to pull yourself out of the swamp” –  Anitra Nottingham, writing for The Thesis Whisperer blog
  • Keep going if you can. Break your important tasks into tiny little pieces and focus on one mini-task at a time.
  • Postpone anything non-essential to give a yourself a little bit of breathing space.
  • Practise mindfulness and set a worry time to calm the churning thoughts.
  • Tell someone I trust that I’m struggling.
  • “This too shall pass”.  Because I have come through this before, I know I will come through it this time too.
  • “whatever your feelings – these reflect your brain state, are not your fault, and millions of others have these feelings too. Of course, knowing this does not make your depression any less painful, but it does mean that there is nothing bad about you because you are in this state of mind. It is a shift in brain state that is painful – depression pulls us into thinking and feeling like this, so these feelings are sadly part of being depressed.” Paul Gilbert, Overcoming Depression
  • Accept offers of help. I feel better when someone:
    • Sends messages that remind me that people do care.
    • Reminds me that I have got through this before and I’ll get through it again.
    • Helps me figure out how to tackle the things that seem to difficult, and to do a little at a time.
    • Keeps me company or helps me to do something that I find overwhelming by myself.
The things I put on my list are some quotes that I liked, advice I’ve read, and things that have helped me in the past. But it is a personal list and what helps me might not work for you. So I’ve put together a list of resources that might be useful.

Self-help resources for depression:

Here’s a few sources of help and advice for with coping with depression:

Where to go for immediate support:

Do I have intrinsic value?

The intrinsic value of something is said to be the value that that thing has “in itself,” or “for its own sake,” or “as such,” or “in its own right.” – Stanford Encyclopedia of Philosophy

Being chronically ill has really shaken my self-confidence.  My counsellor introduced the idea that I have intrinsic value.  She suggested that I think of something I loved like a pet that had done nothing yet I loved it anyway.  She explained that my pet rabbit had intrinsic value and so do I.  She suggested that everyone has intrinsic value and deserves to be loved.

I found this idea tricky from the start.  Firstly, I wasn’t convinced that value is intrinsic to objects, animals or people.  Secondly, and most significantly the idea that I have intrinsic value was so alien to me it was hard to get a handle on it.

My next issue came with the idea that people or animals deserve love because of their intrinsic value.  If the value is intrinsic it shouldn’t be because they deserve it, they should have value just because they exist.

I then thought about how intrinsic value could be related to uniqueness.  Each person, animal landscape only exists once.  There is no one else in the world exactly like me.  Maybe my uniqueness is my intrinsic value.

I still struggled to really get to grips with and absorb this.  I am struggling to ‘get’ the concept itself.  And I’m having trouble with the idea that this particular self (me) has worth beyond what I can do.  I read a few articles  one given to me by my counsellor, and a couple I found on the internet.  It took a week or two of mulling over the ideas before I could begin to pull together a few thoughts.

I think I do have an issue with the intrinsic part of intrinsic worth.  I think value is something that is ascribed to things by others.  There are all kinds of ways of valuing things.  It seems to me that things have intrinsic properties and those properties may have value, but whether or not those properties are valued will depend on whoever is doing the valuing.  There is also a cultural element.  The reasons puppies are considered to deserve love and care isn’t to do with their intrinsic puppyness but because the culture of this society values dogs as companions and pets.  Or because of the value given to innocence and cuteness.

Then I thought about approaching the problem from another direction, by thinking about my own values.  I value sentience, consciousness and recognise that love and care will allow a person to flourish, neglect or cruelty will cause suffering.  Therefore, I believe it’s right that humans should be given that care and love.  It also makes sense from a practical point of view.  Children that are nurtured are more likely grow up resilient and kind, those that are neglected and mistreated are more likely to have physical and mental health problems.

I also see the potential in human beings to grow and change.  Almost everyone has this capacity to some extent.  A person has future potential even if their behaviour to date suggests they don’t deserve care and affection.

Even if I am sceptical of the philosophical concept of intrinsic worth I still think that sentience, consciousness, uniqueness and the potential to grow and change give human value.  I am against unkindness and cruelty for ethical and pragmatic reasons.  And as I am sentient, conscious, have the potential to grow, respond to kindness, and am unique I should value myself in the same way.

I also believe in valuing people for who they are not what they do.  That is the character they show over time. And I believe in overlooking and forgiving people’s flaws (within reason).  I should apply those values to myself too.

The articles I read:

The importance of self-worth – PsychAlive.org

What is the value of a human being? – Leon Pomeroy Psychology Today

Intrinsic vs Extrinsic Value–  Stanford Encyclopedia of Philosophy